Full List of Questions on this Critical Asset Survey (CAS) 2022

Collect the Required Info and enter it into the CAS Survey Link

Select your Network

Select the CCN (CMS Certification Number)

Re-Enter your facility CCN as it appears in the drop down above (6 digits, no spaces, no dashes) Only 1 submission per facility. If you enter the correct CCN and get a "Duplicate Value!" message, it means that this Survey has already been submitted and no further action required!

Submit 1 per facility Only. If you see "Duplicate Value!" message, that means it has already been submitted and no further action needed.

Section Header: Contact Information of Person Completing this Form

First and Last Name:

e.g.: John Doe

Email Address:

e.g.: john.doe@ipro.us

Facility Phone Number:

e.g.: 123-456-7890

Are you the "Primary Emergency Point of Contact" for this facility during an emergent event? Yes/No

Please select your role.

Manager, Facility Administrator, Social Worker, Dietitian, etc.

If other, please specify.

Primary Emergency Point of Contact Mobile Phone Number:

e.g.: 123-456-7890

Section Header: Primary Emergency Contact Personnel Information for this Facility

Primary Emergency Contact First and Last Name:

e.g.: John Doe

Primary Emergency Contact Role:

Manager, Facility Administrator, Social Worker, Dietitian, etc.

If other, please specify.

Primary Emergency Contact Email Address

e.g.: john.doe@ipro.us

Primary Emergency Mobile Phone Number:

e.g.: 123-456-7890

Section Header: Backup Emergency Contact Personnel Information for this Facility

Backup Emergency Contact First and Last Name:

e.g.: John Doe

Backup Emergency Contact Role at Facility:

Bio-Med Technician, Manager, Facility Administrator, Social Worker, Dietitian, etc.

If other, please specify.

Backup Emergency Contact Email Address:

e.g.: john.doe@ipro.us

Backup Emergency Mobile Phone Number:

e.g.: 123-456-7890

Section Header: Emergency Corporate Regional Contact Personnel Information for this Facility

Emergency Corporate Regional Emergency Contact First and Last Name:

e.g.: John Doe

Emergency Corporate Regional Emergency Contact Email Address:

e.g.: john.doe@ipro.us

Emergency Corporate Regional Emergency Contact Phone Number:

e.g.: 123-456-7890

Does this facility have any additional emergency contact personnel? i.e. Director of Operations, Regional Operations Director, Clinical Services Specialist, etc.

Section Header: Additional Emergency Contact Personnel Information for this Facility

Additional Emergency Contact First and Last Name:

e.g.: John Doe

Additional Emergency Contact Role:

Director of Operations, Regional Operations Director, Clinical Services Specialist, Regional Quality Manager, etc.

If other, please specify.

Additional Emergency Contact Email Address:

e.g.: john.doe@ipro.us

Additional Emergency Mobile Phone Number:

e.g.: 123-456-7890

Section Header: Emergency Preparedness: Facility

Does your facility have an emergency preparedness and response plan?

Which of the following emergent event components are included in your facility's emergency plan?

Choose all that apply.

Other, please specify.

Does this facility have an established process for communicating with any of the following before, during and after an emergency?

Choose all that apply.

Are staff members familiar with the contents of the facility's emergency preparedness plan?

How often is the emergency contact information for staff members collected and/or updated?

Choose all that apply.

How often does your facility review and update its emergency plan?

Other, please specify:

Do you need assistance from the ESRD Network to create and/or revise the facility's emergency preparedness and response plan?

Briefly describe the type of assistance you will need in regards to your facility's emergency plan.

Does this facility perform dialysis in a nursing home?

Please provide the name of the SNF/LTC facility.

Can this facility treat any of the following?

Choose all that apply.

Which of the following modality options does this facility offer?

Do you educate home patients on contacting their local utility providers to be identified as a priority customer in the event of an emergency?

Section Header: Utilities: Facility

Electricity Provider Name:

Electricity Provider Phone Number:

e.g.: 123-456-7890

Please select the best option for this facility in regards to the generator status:

What type of fuel does the generator use?

Water Provider Name:

Water Provider Phone Number:

e.g.: 123-456-7890

Does your facility have water treatment back-up capabilities?

(i.e. DI tanks, water delivery, etc.)

What is your facility's emergency plan in the event this facility loses the "MAIN WATER SUPPLY" capability and can not perform dialysis treatments?

Section Header: Emergency Preparedness Facility: Local Emergency Management and Healthcare Coalition

Has your facility established contact with the county's emergency management agency?

What are the barriers to establishing contact with the county emergency management agency?

County Emergency Management Coordinator name:

e.g.: John Doe

County Emergency Management Coordinator email:

e.g.: john.doe@ipro.us

County Emergency Management Coordinator phone number:

e.g.: 123-456-7890

Has your facility established contact with your Regional Healthcare Coalition?

Regional Healthcare Coalition facilitator name:

e.g.: John Doe

Regional Healthcare Coalition facilitator email:

e.g.: john.doe@ipro.us

Regional Healthcare Coalition facilitator phone number:

e.g.: 123-456-7890

Section Header: Emergency Preparedness: Patients

How often does your facility provide emergency preparedness education to patients?

Choose all that apply.

How often does your facility collect emergency contact information for patients? i.e.: current street address, phone number(s), family member/caregiver contact information, emergency contact information, ect.

Choose all that apply.

How often does your facility conduct emergency preparedness drills with patients?

Choose all that apply.

Please select all "Emergency Preparedness Drills and/or Emergency Procedures" that are conducted with dialysis patients at this facility.

Choose all that apply.

What is the name of the transportation provider most frequently used by patients receiving treatment at your facility?

Transportation provider phone number:

e.g.: 123-456-7890

Do you have another transportation provider that is frequently used by patients receiving treatment at your facility?

What is the name of the secondary transportation provider that is used by patients receiving treatment at your facility?

Transportation provider phone number:

e.g.: 123-456-7890

Which backup communication systems does your dialysis facility utilize if landline phones are not working?

Choose all that apply.

Other (please specify):

Do you have the capability to change the voicemail message of your phone system during an emergency to provide information on your open/closure status and a phone number patients can call for information?

Section Header: Primary backup facility location where patients will be sent if your facility is unable to treat patients

Primary backup facility name:

Primary backup facility contact name:

e.g.: John Doe

Primary backup facility email address:

e.g.: john.doe@ipro.us

Primary backup facility phone number:

e.g.: 123-456-7890

Section Header: Secondary backup facility location where patients will be sent if your facility is unable to treat patients:

Secondary backup facility name:

Secondary backup facility contact name:

e.g.: John Doe

Secondary backup facility email address:

e.g.: john.doe@ipro.us

Secondary backup facility phone number:

e.g.: 123-456-7890

Section Header: Form Status

Complete?